Services Engineering and Management Summer School, Helsinki University of Technology, August 28-September 2

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Ashok Agarwal, Insittute of Health Management Research, India

Introduction by Paul Lillrank

Extreme differences between Finland and India, good for academics

Possible for them to jump into higher level of technology, avoiding some of the blind spots of early adopters

[Ashok Agarwal]

Bring the science of management to health care

Like many other countries, health care is managed by doctors

Agenda

Equity

How to measure it

Comparison of developed and developing coutnries

Millenium goals

Indicators of goals

Difficulty between defining equity, versus equality

Equality: compare various attributes of a country or person, in a semblance

Different background, financial, social

Hence provision of services is equally spread out

Equality is value-free

Equity means social justice

Several disparities in wealth, health care, democratic freedoms

Can understand inequities in wealth, from inheritance, and some people work harder than others

Everyone should have equal access to health, though

Health equity is multidimension, includes all of the other special acts in living

No matter where they're living, health level, age group

Bring health differentials as low as possible

Dimensions of equity in three parts:

Economic equity

Provision

Health outcomes

There's horizontal equity and vertical equity

Horizontal: people who have the same neeed receive same services

Vertical: people with more needs get more services

Extreme poverty: World Bank defines as less then $1 per day

However, different purchasing powers

One other way: caloric intake

People of different age groups, of different sexes, have different values of intake without malnutrion

2000 calories per day

Also define poverty as resources, and access to services

Ten richest countries in the world

Do they have the best health status?

Do they provide equal health care?

Consider a world where they talk instead about taking care of their babies

More linked to public health than to engineering

Number of deaths of infants, under age of one year

Talks to nutrition status of the woman, health care of the woman while pregnant, health care, ... health status of the child when born

Lowest infant mortality rate:

Only 2 of 10 richest countries on the list

Range of infant mortality rates around the world

Countries more than 150/1000 live births

Singapore lowest at about 2

Expenditure health in different countries in the world, both public and private sector

Low income, middle income, and high income countries

Low income countries spend less per capita

India about 5%, low

Developed countries spend about 10%, and the U.S. is spending about 1/6 of GDP

Absolute numbers in spending:

Low income countries spend about $20 to $30 per person per year

Middle income countries spend about $200

High income countries spend about $3000

U.S. spends about $6000 per capita per year

India: typical example of a undeveloped country

Public health care only 30%

82% is private, out of pocket

Have just started private health care

Rich people can get either free or fee services

Low income countries have low life expectancy

Sri Lanka an exception, infant mortality rate is relatively low

South Africa is an exception: apartheid, high infant mortality rate

1987: Millenium Development Goals

Set up by U.N. and World Bank

Aim for 2015

Goals not equally spread out

Defines according to each country, each region in each country, based on 1990: environment, health care

#1 target: eradicate extreme poverty and hunger

Medicine won't improve everything

#2: achieve universal primary health care

Educated women have better health

#3: gender equiality

#4: reduce child morality

#5: improve maternal health

Why is goal setting important?

According to each countries' relevance

Important to mobilize world resources

Goals allow U.N. system to monitor progress

Last time: eradication of smallpox, a disease know for 5000 years that was highly contagious

In the 1970s, joint work, countries came together to say to eradicate one disease in the century

Up to $10000 reward in each country, to find an incidence of smallpox

Where are we?

On poverty, we're nowhere, because we don't know how to measure it

In India, have a different definition of poverty

Haven't been able to measure over the past 6 or 7 years

Wealth is increasing globally, but in only certain classes of people

Many countries in Africa, GDP sometimes goes down

HIV/AIDS: nothing has been achieved in 2005, because the goal is different, to halt new cases

Safe water, somewhat better, one of the most basic for health care

Goal to reduce child mortality

2015 goal

Smallpox was eradicated in 9.5 years, without today's technology

Indicators:

Under 5 mortality rate, reduce by 2/3

Infant mortality rate

Measles

Under five rate in high-income countires < 5 per 1000 live births, and >100 in low income

In India, 26 million births per year: 5 Finlands

Highest proportion of global annual live births, but also highest proportion of neonatal deaths

Deaths less than 4 weeks are mostly related to mother's health status, or delivery conditions

Under-5 mortality rate is coming down

India's population is 1.1 billion

Diverse

Each state, 60 billion to 150 billion

In south, Kerala is poor, yet lowest infant mortality rate

Orissa, another poor state on the east, has highest infant mortality rate (similar to Africa), yet bad infant mortality rate

100 years ago, Kerala had a policy of educating masses, families working together

Kerala has infant mortality rate, comparable to the U.S.

Kerala has electricity rate of 90%, Orissa has about 40%

Punjab, Delhi have higher mortality rates, and the ratio of men to women is high, biologically incorrect

Death of the woman while pregnant, or within 6 weeks of termination of pregnancy

In India, preparing adolescents, a lot of women get pregnant at 18 or 19

Differential in maternal mortality health: 1100 per 100,000 live births in sub-Saharan Africa, compared to 12 in industrialized countries

In sub-Saharan Africa, a woman will be pregnant 5 or 6 times in her lifetime

Skilled birth attendants at time of childbirth

About half of children in the world at born at home

Chances of a child or mother getting infected is very high

In poor India, 10% have access to nurse or doctor, whereas in rich India, 90%

Goal 7: Combat HIV/AIDS, malaria and other communicable diseases

Use of condoms

Knowledge of women

In 2005, global 1% with HIV, but about 6% in sub-Saharan

Limitations to achieving Millenium Development Goals

Difficult in countries that aren't well-defined, e.g. wars

Poorer people have to pay out of pocket expenses more often

When a poor person has to go to a hospital, 25% will have to dispossess something

Prescription to remove inequity?

Wish there was something, no standard prescription, has to vary country by country

Regions in mountain, by sea, inequal distribution of resources

What needs to be done?

Firstly, need resource allocation related to social and health needs

Some have other priorities, e.g. war

Education

People will live near jobs, health care has to go where people are

New technology can be distributed

Must be someone who looks at quality of care at national and regional levels.

Lots of centres provide free services, but people don't go there

Don't understand why

In fact, people go to public sector, spending a lot of money, to get the same services

Often, go to illegal doctors, quacks

In India, one major factor: unreliability, never find a doctor or nurse there or clean facilities

People would rather go to a private practitioner who will serve quickly

Most data not collected in a way that is useful

Lots of data, not churned out into information used in policy

How to monitor and evaluate health equity?

One research says: guided by values

You collect data, make it information, but must use it to provide care to the population

Hard to measure equity directly

Recommendation:

More resources must be provided to health care, particularly in developing countries

Resources not just money, also trained manpower and infrastructure

Often find the building good, and doctors and nurses are there, but aren't trained well

Should be a pro-poor approach

Public funding should be distributed according to distribution of people, where they need it, even in special needs

Public/private partnership is difficult, defined differently

Instances where government are providing health care at high cost, and outcomes are quite low

There are cases where government could outsource to private, at same or lower cost

Instances in Cambodia and India, no cost to patients, health care is better

Health financing models, either by government or by companies, and others can't get it

Micro-health insurance

India is experimenting with community health insurance, e.g. 1 million people with access to a designated health system

Generic/research questions:

Is the equity definition correct?

Found more than a dozen definitions, most often defined as what is inequal (in health care needs, expenditures)

Equity to reduce disparities: people with more needs should get more resources

Who provides? government, people, private sector, NGOs?

Why is quality in health care intangible?

[Questions]

Equity. Horizontal, same care to same needs. Can this definition of equity really work in a wealthy society? Curve flattens out at $700-$800 per person, then spending more money doesn't improve health. Amartya Sen 1995 and Robert Fogel 1993 have different views. Fogel says in U.S., main obstacle is the concept of equity.

Definition of equity is not standard

There's 5000 ways to lose weight

Sen: equity is not in a narrow sense, it's multidimensional.

Ability of the people to access health care, or any other public good

Thus inequitable

Fogel says there's also moral behaviour, not just determined by body or environment, but by also how you choose to live your health. If this is ignored, then the consequence is health totalarianism. In Nordics, this isn't far away. An issue of individual freedoms.

Living the life you want to live is a small decision

In poor countries, government resources are very limited

Obesity a bigger problem than malnutrition, increasing most in developing countries with bad foods. Should be addressed on a U.N. level. U.S. health care, diabetes at age 20 requires being on machines, cost of life.

Obesity is behaviour.

How much education about obesity?

Agree, more education should be on health behaviour.

Newfound wealth is in a certain class of people.

International problem. Smallpox eradicated because all countries came together. Some issues difficult not just internationally, but within a country. e.g. polio vaccination, outbreaks in India.

Diversity, 6 billion people around the world

In 1970s, diversity, 4 billion people, but the whole world came together to talk about one problem, smallpox.

This wasn't about control, it was eradication.

Uniform will, manageable input. Countries came together.

Politics and religion. A lot of health resistance is by religion communities. Mullahs. Person who wanted to set up a condom factory in Bangladesh, said that privately would support it, but not publically.

Management view. What kind of health care service providing system, service production system could tackle this? Probably not the same as in the rich world. No alternative health production system, so that poor countries have to wait for GDP to grow. Average return per user, e.g. building a mobile cell phone for under $20, or Negroponte computer < $100, lean production.

Jakur artificial knee, made of aluminum.

Health care is limited by doctors.

Doctors use medicines and technologies, which increase cost of health care.

Artificial limb is provided free to people. Cost is less than $1000.

Eye care, cataract surgery.

Do this on a camp basis, instead of at hospital at $200 to $1000, do it at $10 per person.

Infection rate and complication rate is as low as a hospital.

Can bring the cost down, but need to take it out of doctor's purview.

Who is responsible for ensuring health care? A lot of stakeholders. People. Education.

Everyone has to pitch in.

Kerala, brought in the right time, 100 years ago, whereas in other states only 10 years ago.

From political theory, government is responsible to ensure equity of people. Can't ask private sector to do this. Businesses tend to segment markets. Asking them to give up this fundamental principle is not sustainable.

In Finland, it has been NGOs. Service that public sector is offering, has been first developed by NGOs. When the knowledge has been gained, public sector takes them, and the NGO focuses elsewhere. Health clinics on maternal care.

Am an NGO.

They don't necessarily belief in government.

Governance doesn't come up with something new. NGO doesn't have the rights to make it universal.